| NPI | 1073802526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 62433) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 60629) |
| 261QM0850X Clinic/Center Adult Mental Health (Licence: MN 62433) | |
| 261QM0850X Clinic/Center Adult Mental Health (Licence: WI 60629) | |
| Enumeration Date | 2011-04-06 |
| Last Update Date | 2020-03-11 |